Accountability Report

FY 2003

Submitted September 11, 2003

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Section I - Executive Summary 1. Mission and Values The South Carolina Department of Mental Health’s mission is “To support the recovery of people with mental illnesses.” A recovery approach to care embraces consumers’ and families’ medical, social, educational, spiritual, and cultural needs and helps them to find affordable, decent homes and meaningful employment.

The Department’s mission, its priorities, and its values are outlined in the DMH strategic planning document, “Making Recovery Real,” published in 2002. Specifically, our priorities are adults, children, and their families affected by serious mental illnesses and significant emotional disorders. We are committed to: • eliminating stigma and promoting recovery; • achieving our goals in collaboration with

all stakeholders, • Science-to-Practice services – building a

system of care using evidence-based practices;

• and to assuring the highest quality of culturally competent services possible.

Our values are respect for the individual, support for local care, commitment to quality, and dedication to improved public awareness and knowledge.

2. Key strategic goals While the long-term strategic goals of the Department are defined in “Making Recovery Real,” DMH is also committed to accomplishing present goals as well in community services, finance, best practices, children’s services, hospital diversion, the criminal justice system, and more.

When asked their impressions of the South Carolina Department of Mental Health, behavioral health care professionals from other states often comment on the growth of community services in South Carolina. Foremost among the Department’s goals is to continue to build a community system of care.

To that end, for example, the Department is reducing the numbers of its long-term hospital beds and moving consumers, staff, and other resources to the community, where possible. DMH supports the federal Olmstead ruling, requiring that states serve patients in the least restrictive settings possible. Our Recovery philosophy and our nationally recognized Toward Local Care (TLC) program place a priority on moving patients from costly inpatient facilities to less restrictive community alternatives.

With respect to finance, budget cuts since 2001 necessitate that senior leadership continue to emphasize efficiency in order for DMH to receive a strong return on its limited investments. Management is implementing performance-based contracting so that mental health centers, hospitals, and all organizational components’ funding will be based on contractually agreed upon outcomes. The Department also continues to work on a new funding formula that will determine more equitably than in the past how much money centers and hospitals receive.

Implementing evidence-based/ best practice clinical programs is another way the Department will make certain that its resources are being used wisely. Clinical programs considered “evidence-based” are those with data to prove that they work, so DMH will continue to roll out such programs where possible.

In addition, the Department wants to help establish a statewide system of care for children. Children’s services in South Carolina are fragmented, and the Department, in concert with Clemson, the Federation of Families, advocates, and other state agencies, is exploring new approaches to make certain that children and their families’ needs are met.

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Furthermore, senior leadership is striving to place more crisis oriented services in the community. The benefits of these programs include an improvement in the pre-screening of patients and avoidance of unnecessary hospitalizations; a reduction in the number of admissions to our own psychiatric hospitals; a reduction in the numbers of patients waiting in local emergency rooms; and support for psychiatric beds in the community. Achieving this goal will depend upon a solid collaboration between the Department and its stakeholders.

With the increase in South Carolina’s population has come a growth in the numbers of people with mental illness coming into contact with the criminal justice system. An important goal for the Department is to continue to strengthen its relationship with law enforcement and the judicial system. With the proper community supports in place, South Carolina will take the lead in minimizing the criminalization of people with mental illnesses.

3. Opportunities and barriers The Department is opportunity-rich; however, according to the “President’s New Freedom Commission on Mental Health Report,” the primary barriers faced by state mental health departments nationwide in taking advantage of opportunities are inadequate funding and stigma.

To address stigma, one of DMH’s stated values is dedication to improved public awareness and knowledge. The Department believes that if citizens are better educated about mental illness, then there will be less discrimination, as in health care benefits; there will be less fear, hence more support of people in recovery; the media will be more sensitive and fair in its coverage; legislative and other governance bodies will be more apt to provide funding and other support.

Through presentations to civic groups; briefings with reporters and editorial boards;

public walks and rallies; senior leadership’s regular meetings with key legislators; the efforts of advocates and the boards of community mental health centers, DMH and its stakeholders continue to wage the battle against stigma. The Department’s own SWOT analysis (Strengths, Weaknesses, Opportunities, Threats) contends that progress is being made and that, today, the general public is more aware of the needs of people with mental illness.

Among the strategic challenge themes identified in the SWOT analysis are: 1. Enhance services for adults and children

through Evidence-Based and Best Practices;

2. Improve the Department’s information system to provide leadership with better management tools;

3. Improve the Department’s quality improvement processes;

4. Strengthen public education/advocacy; 5. Determine better ways to fund our centers

and hospitals and provide financial incentives to serve more people in the community;

6. Provide cost effective training in clinical practices that are evidence-based; and

7. Promote the Recovery approach in mental health care.

But, the loss of over $43 million in state funds in the past two years and over 800 full time employees has meant that DMH must choose its priorities carefully, yet be in a position to take advantage of new opportunities.

4. Major achievements from past year The Department ended the year with many accomplishments in spite of the loss of more state funds. Chief among these was the rolling-out, statewide, of several evidence-based/best practices in clinical programs

For example, the year saw eight Assertive Community Treatment (ACT) teams being formed in the community to bring a

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specialized, intensive level of care to people with serious mental illnesses. To improve services to children and widen the safety net, the Department began five Multi-Systemic Therapy (MST) programs and expanded its school-based services programs to include 422 schools in the state.

Four supported employment programs, a collaborative effort between DMH, SC Vocational Rehabilitation, and Johnson & Johnson, are up and running, providing meaningful jobs to consumers. A new approach for prescribing medicines – the South Carolina Medication Algorithm (SCIMAP) – is being implemented at two mental health centers and the Medical University of South Carolina. Mental Health Courts have opened in Charleston and Columbia, part of a series of steps to divert mentally ill people from jails.

In addition, consumers also benefited from the opening of 170 new apartments and housing units; the DMH now has over 1,900 consumers in decent, safe, affordable housing, 1,253 of which were built through partnerships with non-profit organizations. Trauma Services, a new best practice and a field in which DMH is a pioneer, have opened at four sites, including the Charleston/ Dorchester Mental health Center, which also operates a mobile crisis program.

Another notable achievement was the virtual elimination of lists of people waiting in jails to receive evaluations or treatment at DMH’s secure forensics hospital. Through reallocation of personnel, re-configuration of workflows, and opening of a 32-bed step-down unit on hospital grounds, the Department has expedited the admission and discharges of forensics clients.

A major source of concern for the Department and its stakeholders has been the numbers of people coming to local emergency rooms for treatment, particularly those with co-occurring

disorders (substance abuse and mental illness). DMH senior leadership provided $500,000 last year to start or enhance four crisis stabilization programs around South Carolina for people suffering from a co-occurring disorder and $400,000 this year.

Joining the DMH community mental health centers in the operation of the substance abuse and mental illness programs are members of the SC Hospital Association, local commissions of the Department of Alcohol and Other Drug Abuse Services, county sheriffs’ departments, and other community groups.

Additionally, $2M has been allocated to expand other crisis stabilization efforts through out the state. The Department is committed to partnering with local hospitals to ensure that all citizens receive the services they need, whenever and wherever their condition their condition demands.

5. How the accountability report is used to improve organizational performance

Realizing goals and striving for excellence are inherent in the DMH culture. The leadership of the agency has turned this philosophy into practice. Further, management encourages all employees to embrace a work ethic that calls for self-evaluation and continuous improvement.

Two of the Department’s management staff have become Examiners for the Governor’s Quality Award, and several of its senior leadership council have already completed training in how to use the Accountability Report for agency assessment and improvement. For the past two consecutive years, DMH conducted a self-assessment using its Accountability Report as the primary source document, and from these assessments senior leadership identified key areas for improvement.

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♦ Section II – Business Overview The Department of Mental Health (DMH) is a major state agency, providing an integrated continuum of mental health care to the citizens of South Carolina. Its chief executive officer is hired by a Mental Health Commission, a seven-member governing body that is appointed to five-year terms by the Governor, with the consent of the state Senate.

The agency served 92,647 clients in FY 03 – 6,658 in our hospital system and 89,743 through community programs. Approximately 56,000 were adults, and 36,000 were children. With a total operating budget of $340 million, state appropriations comprise approximately 50%. About one-third of the state funds are used to match federal Medicaid dollars.

Through legislative mandate DMH is the governing authority over the state's mental hospitals, community mental health centers, and facilities for nursing care and inpatient alcohol and drug addiction. All inpatient facilities operated by the agency are inspected by the Department of Health and Environmental Control and are accredited by national certifying bodies. We are subject to corporate/legal compliance with state and federal laws governing health care organizations and state agencies.

Each community mental health center (CMHC) has its own governing board appointed by the Governor upon the majority recommendation of the county legislative delegation, and local boards advise on policy issues for their respective catchment areas. The 17 CMHCs provide services within their respective counties and operate within the policies and guidelines set by DMH.

Our workforce includes 5,170 (permanent) employees, 49% in the community system,

42% in our inpatient setting, and 9% administrative. Forty-nine percent of our employees are White, and 49% are African-American. Approximately 25% of job positions require advanced degrees. Males comprise 27% of our workforce and females 73%. Four percent of our positions are classified as Executive, 47% professional, 23% paraprofessional, 11% clerical, 4.7% technician, 9% trades/skilled craft, and 1.6% security.

The Department operates one inpatient facilities in Columbia and two near Anderson, along with a statewide network of seventeen community mental health centers (CMHCs) serving clients in every county of the state. The catchment areas covered by each of the 17 CMHCs range from part of a county to seven counties.

Key customers segments linked to key products/services Our key customers are adults, children, and their families who are affected by serious mental illnesses and/or significant emotional disorders. Their key requirements, and how we measure our success in meeting their requirements, are presented in Table 1. The key processes are the best practice programs designed to meet the key requirements of our customers.

Key stakeholders Key stakeholders are the organizations, individuals, and agencies that impact our key customers. Key stakeholders include: other state agencies, legislative, executive and judicial branches of government, public health systems, suppliers and vendors, federal regulators and accreditation bodies, SAMHSA (Substance Abuse and Mental Health Services Administration) and other funding sources, advocacy organizations, the media, taxpayers, and the communities in which we operate.

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Key suppliers DMH contracts with several major vendors to provide services to our clients. The Campbell Veteran’s Nursing Home in Anderson, SC, a 220-bed nursing home, is operated through a contract with Health Management Resources, Inc. DMH also contracts with Just Care, Inc. for the general operations of the agency’s inpatient forensic services. Located on DMH property leased to this provider, DMH

provides some of the professional treatment staff, while the vendor provides general nursing, room and board, etc. Our community mental health centers contract with a number of local providers such as general hospitals, private practioners, and other organizations for a variety of professional services including local inpatient care, residential treatment and other general medical care for agency clients.

Table 1 KEY CUSTOMER PERFORMANCE MEASURES Customer Key Requirements Key Measures Key Processes

Adults with Serious Mental Illnesses Satisfaction

Consumer Perception of Care (MHSIP).

Consumer-to-Consumer Evaluation.

Evidence-Based or Best Practice Programs: Crisis Stabilization, Case Management (ACT/PACT), Dually Diagnosed Program, Criminal Justice System

Interventions, TLC, Trauma Services Employment Program Housing Program

Functional Improvement

BASIS 32 (Clinical Assessment)

Symptom Reduction

Employment Number Employed

Housing No. of Units

Children with Severe Emotional Disturbances

Functional Improvement

CAFAS (Clinical Assessment)

Evidence-Based or Best Practice Programs: School-Based Programs, Multi-Systemic Therapy (MST), Juvenile Justice Diversion, & Trauma Services.

Symptom Reduction

Parental Satisfaction

Parent’s Survey

KEY MEASURES OF ORGANIZATIONAL EFFECTIVENESS AND EFFICIENCY Domain Measures

CMHC Hospital Admissions Bed Day utilization Avg. Days Btw. Hospital Discharge and Date seen by CMHC % of Clinical Contacts for Adults with Major Mental Illness % of Clinical Contacts for C&A with Major Mental Illness

Inpatient ORYX Measures: Restraint/Seclusion Use; 30 Day Readmission Rate; Length of Stay Admission Rate Bed Days Discharges with CMHC Appointment

Program Cost Comparison by Facility and/or Program Medicaid Revenue

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Table 2 Expenditures/Appropriations Chart

FY 01-02 Actual Expenditures

FY 02-03 Actual Expenditures

FY 03-04 Appropriations Act

Major Budget Categories

Total Funds

General Funds

Total Funds

General Funds Total Funds General

Funds

Personal Service 184,770,266 114,414,155 178,089,941 108,260,084 178,335,895 105,626,563

Other Operating 81,349,180 17,521,015 84,953,287 14,523,999 90,063,030 21,549,047

Special Items 1,174,064 200,200 592,192 192,192 592,192 192,192

Permanent Improvements

15,679,499 0 7,753,328 0 0 0

Case Services 19,022,235 11,517,712 11,576,135 2,058,518 16,688,401 8,444,691

Fringe Benefits 54,946,984 34,284,167 52,694,431 33,394,587 54,810,848 33,625,800

Total 356,942,228 177,937,249 335,521,510 158,429,380 340,490,366 169,438,293

Table 3 Strategic Goals Key

Challenges (Identified in Section I,3)

C&A Goals FY 03 FY 04 FY 05

School-Based 400 Programs 440 Programs 484 Programs #1 MST Licensed Trainer, 5 Programs 8 Programs #1 Wrap 8 Centers 10% Increase 10% Increase Trauma Assessment Tool, 3 Programs 8 Programs #1 Juvenile Justice 2 Programs

Adult Goals Employment +10 %, 4 IPS Models +10 % +10 % #1 Crisis Services 8 Programs Housing +50 Units +50 Units +50 Units #1 ACT/PACT 3 Programs 7 Programs #1 Dual Disorders 5 Additional Programs All Centers #1 Criminal Justice 2 Programs 3 Programs TLC Program 598 Capacity +10 % Trauma Assessment Tool, 3 Programs 8 Programs #1 Medication Algorithm 2 Programs #1 Recovery Training 9 Programs #7

Systems Goals

Data Systems Data Entry & Retrieval #2 Pub. Ed. & Advocacy All Centers have Plan #4 Cultural Competency 5 Centers/Facilities InPt Outcomes ORYX Measures: all inpatient Best Practice Trng. 5 Programs #6 Resource Re-Allocation Develop Formula

Develop Incentives Bed Utilization Funding Formula

#5

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Organizational Structure.

South Carolina Mental HealthCommission

Office of theState Director

General Counsel

Internal Audit

CompliancePolicy Regulations/Risk Management

S. C. Department of Mental Health Organizational Chart

Chief of Staff Public Safety

PublicInformation/

Communication

LegislativeAffairsFacility Planning

Division ofEducation, Training

and Research

Division ofAdministrative

Services

Division ofBehavioralHealthcare

Human ResourceServices

Support Services

Financial Services

IT

Center forInnovation

Research

CommunityCollaboration

Centers

TLC

Hospitals

Forensic ServicesPerformanceImprovement/

Quality Assurance

Alcohol & DrugServices

Pharmacy

Health CareReform

Consumer andFamily Affairs

Cultural ActionCenter Client Advocacy

Residency Training

Accreditation

Housing EmploymentSpecial

PopulationsLong Term Care

DMH2A

Medical Director

Children & Families

Medical Chiefs

Education, Training & Research

ContinuingMedical Educ. &

Staff Dev.

OutcomesEvaluation

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Section III Category 1 – Leadership 1. How do senior leaders set, deploy and

communicate: a) short and long term direction, b) performance expectations, c) organizational values, d) empowerment and innovation, e) organizational and employee learning, and f) ethical behavior?

From stakeholder and field input, and in accord with legislative mandates, DMH has developed a clear mission/values/priorities statement, a responsive set of strategic priorities, and an ambitious, coherent strategic plan. From these documents and guiding principles, the Mental Health Commission and senior leadership set the short- and long-term direction of the agency.

It is leadership’s responsibility is to see that performance expectations are met; that DMH values are taught; that employees and customers are empowered; that DMH employees work in an environment that promotes creative thinking and learning; and that all employees provide their services in an ethical manner.

Senior leadership communicates the Departments values and priorities through a variety of ways, such as publishing the minutes from governance meetings; conducting quarterly meetings; meeting regularly with CMHC boards; holding “Kitchen Cabinet” meetings with advocates; publishing newsletters and other internal reports; posting information on the Intranet site; meeting with editorial boards, key legislators, and other influencers; and using the interactive capabilities of SC ETV to reach the field.

The consumer, or customer, plays a vital role in the Department’s realization of its values and priorities. Consumers and other stake holders participate in the major committees; serve on mental health center

leadership teams and boards; and conduct consumer satisfaction surveys.

The Department places a high value on research-based outcomes for clinical programs. All new programming must be of this genre. Existing programming must be brought into line with best practice outcomes. Even so, organizational components are encouraged to submit data on locally developed programs that meet, or exceed, the outcomes of established practices. Conferences and stake holder meetings feature educational reports on state-of-the-art treatment approaches, and the Department’s bi-monthly publication, Images, routinely features model DMH programs.

2. How do senior leaders establish and promote a focus on customers?

At DMH, consumers, or customers, are the agency’s reason for existing. Through consumer advisory boards, consumer employees, consumer conducted surveys, advocacy groups, and other stakeholders, the agency is able to maintain its focus on providing excellence in customer satisfaction. Further, as described in Table 1, senior management is able to review key measures to determine how well the agency is doing with customer satisfaction.

3. What key performance measures are regularly reviewed by your senior leaders?

Customer satisfaction, symptom reduction, functional improvement, housing and employment are part of the data reviewed regularly by leadership. In addition, every month the Commission and senior leaders review “dashboard indicators,” which provide comparative data on organizational efficiency and effectiveness. Copies of the “dashboard indicators” are provided to all DMH management, CMHC and inpatient facility directors, and CMHC board chairs.

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4. How do senior leaders use organizational performance review findings and employee feedback to improve their own leadership effectiveness and the effectiveness of management throughout the organization?

The agency is in the early stages of using performance improvement methods to produce systems change. While there have been quality improvement teams for years, the Department has just begun to learn from the teams’ findings and create a systems approach to improvement. The Department is reorganizing the structure of its performance improvement system to tracking performance improvements, to encourage the creation of more teams, and to transfer knowledge throughout the system. Many members of the leadership team are graduates of the South Carolina Executive Institute, and the exchange of learnings between leadership members strengthens the individual and the full team. 5. How does the organization address the

current and potential impact on the public of its products, programs, services, facilities and operations, including associated risks?

DMH is aware of its obligation to provide the best possible care and treatment in an environment that ensures patient, staff, and public safety. As part of its strategic planning process, the Department’s own SWOT analysis (Strengths, Weaknesses, Opportunities, and Threats) reaffirmed its focus on public safety.

Regular reviews are conducted to ensure that standards are met for programs and procedures. All inpatient facilities are licensed by DHEC, and all are fully accredited by either the Joint Commission on Accreditation of Healthcare Organizations (JCAHCO) or the Commission on the Accreditation of

Rehabilitation Facilities (CARF). All CMHCs are also CARF accredited.

Further, the DMH Corporate Compliance Committee develops plans to strengthen our auditing procedures as necessary, and our Office of Internal Audit, answerable directly to the Commission, regularly reviews all DMH activities (administration, inpatient, and community) to ensure accountability, ethical behavior, and legal compliance. Also helping the Department assess its impact on the public are center boards, advocacy groups, the South Carolina Hospital Association, and the Medical Association. The Department subscribes to a “press summaries” service, reviewing all newspaper articles and editorials in the state to maintain an awareness of public concerns and opinions. We hold periodic meetings with probate judges across the state to address issues and concerns. The state director meets regularly with members of the legislature, news media, editorial boards, and other community leaders to provide information about the Department. 6. How does senior leadership set and communicate key organizational priorities for improvement? Organizational priorities for improvements are identified through the strategic planning process, through leadership’s regular meetings with key stake holders, and by review of performance measures. Data used to assist leaders in establishing priorities for improvement include “dashboard indicators,” quality assurance and risk management findings, and performance improvement team results. These priorities for improvement are communicated and/or deployed through the avenues identified in Section 1.1. In addition, we are involved in the Mental Health Statistical Improvement Project (MHSIP), a national effort to produce reliable measures of recovery.

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7. How does senior leadership and the agency actively support and strengthen the community? Include how you identify and determine areas of emphasis. The Department supports the communities it serves and is committed to educating the public about mental illness and reducing the stigma associated with the disease. During the past year:

• DMH and advocates held a Recovery Rally as part of May is Mental Health Month at the State House, with over 1,000 people attending. The focus was to educate legislators about mental illness and stigma. The Governor signed a Proclamation declaring May as Mental Health Month, and a Concurrent Resolution was issued. Additionally, proclamations declaring May as Mental Health Month were received from 85 cities and towns across the state.

• The Art of Recovery project, showcasing the artistic skills of people who receive care from DMH, has featured over 225 works from more than 200 artists. The first move into the community was held May 6 - June 1, 2003, and featured 37 pieces of artwork at the Wachovia Gallery of the Richland County Public Library.

• Over 40 staff and others are involved in the Palmetto Media Watch Program, which gives feedback to the media on coverage of mental health issues and how people with mental illnesses are portrayed.

• DMH’s Teen Matters website has had 457,919 hits since it went online in 2000.

• DMH staff, consumers, and family members educated college

journalism students about mental illnesses, with presentations to 11 classes.

• DMH’s Speakers Bureau made 26 presentations to civic and community groups this past year on mental illness and stigma.

• DMH staff made 373 presentations to schools, 135 presentations to civic groups, 88 presentations to churches, 296 media contacts, and 242 other public information contacts in the community. The Office of Communications authored 25 positive news releases and received positive coverage on 17 in 44 media outlets.

• DMH’s 9,050 volunteers served 140,515 hours and generated a total investment of over $ 5 million in time, money, and goods.

• DMH employees contributed $94,167 to the United Way, making it the third largest contributor in state government.

• DMH management, senior leadership, and facility/center leadership serve their communities by participating on boards of service organizations and community initiative committees. DMH senior leaders serve on over 80 such boards, and CMHC/facility directors serve an additional 84.

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Section III

Category 2 – Strategic Planning 1. What is your Strategic Planning

process? The Department has a three-year planning cycle, with annual updates for major plan refinements. In November, 2001 the agency conducted a statewide, stakeholder-driven, strategic planning initiative to chart system changes for the next three years. More than 600 stakeholders took part in this planning process: consumers; probate judges; law enforcement; private practitioners; hospital emergency room staff; human service agency staff; local government officials; and DMH employees. Input was collected through focus group exercises, aggregated, analyzed, and prioritized around specific targeted activities, including consumer need, human resource, financial, data management, and support strategies. The process was interactive and included feedback and action loops to keep the planning relevant to consumer identified needs.

Strategic planning in the Department is not a static event. It is a systematic, on-going process that responds to a changing environment. Plan refinement and goal setting are a function of our Commission, Governing Council, Transition Council, State Planning Council, major committees, and other representative bodies who give form and substance to the agency’s goals. These groups also address the details of agency planning, such as: • per-capita funding formula overhaul to

ensure equity of service and allocation across centers;

• budget reduction strategies to deal with diminished appropriations while maintaining core clinical programming;

• monitoring of the strategic plan;

• right-sizing facilities and transferring funds to community programming; and

• human resource development, succession planning, recruitment, and training.

This process allows senior leadership to reaffirm that all plans and strategies are in accordance with the stakeholders’ requirements and the goals of the Department.

Central to our challenge is the improvement of services to priority mental health consumers with decreasing resources, to which the Department has responded by absorbing its budget reductions in areas serving non-priority consumer groups, in central administration, and inpatient facilities. These cuts have been in keeping with our strategic plan which gives priority to community program expansion of evidence-based practices for adults, children, and their families who are affected by serious mental illnesses and significant emotional disorders.

The plan creates programs in under-served areas of the state or creates “Centers of Excellence” in evidence-based practices whose mission is to propagate program expansion. It improves the Department’s information system, quality improvement processes, training, and program funding mechanisms. Each of these areas is core to promoting a Recovery-based system of care consistent with the DMH mission and the priorities identified by stakeholders in the strategic planning process.

2. How do you develop and track action plans that address your key strategic objectives?

The Department’s Governing Council members assumed individual responsibility for statewide implementation, oversight, and

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deployment of specific objectives. To guide their process a work-plan was developed for each objective using an adaptation of the Plan/Do/Check/Act (PDCA) model. The workplan includes key “deliverables” --measures of progress which are reported to senior leadership and the Commission quarterly.

3. How do you communicate and deploy your strategic objectives, action plans and performance measures?

To deploy the objectives at the local level, each division, community mental health center and inpatient facility submitted its own PDCA to Governing Council, specifying how it would contribute to the agency goals. Quarterly progress reports from each organizational component are reviewed by Governing Council and the DMH Commission. The Community Plan deployment strategy is intense and detailed. Staff and management are able to focus their work on the priorities of the agency as identified by the stakeholders. Performance measures are tied to outcomes, which are based on program priorities, which are defined by stakeholder feedback, which define budget allocation and program development. To communicate the “Making Recovery Real” plan to staff and stakeholders, the agency undertook a broad-based educational effort. Articles in the agency newsletter Images, discussions at Center/facility directors’ meetings, presentations at “All-Hands Staff Meetings” and Quarterly Stakeholder Meetings, Internet and Intranet web postings, and ETV closed-circuit broadcasts to employees are a few of the avenues that DMH leadership used to meet the director’s mandate that “all employees and stakeholders should be aware of where we are going and how we are going to get there.”

Budget reductions over the past two years have severely and repeatedly jeopardized the strategic plan timetable due to the personnel costs of program implementation or program expansion.

While there is justifiable concern that the agency’s budget cuts will endanger these initiatives and some objectives will clearly depend on external funding, Governing Council has committed itself to implementing the plan. In support of these objectives Governing Council tentatively set aside eight million dollars of its funding allocation for this purpose. Even with further budget reductions, the current set-aside is as follows: $1.5M – Community Diversion programs $3.8M – Crisis Stabilization programs $1.5M – TLC $800T – Evidence-Based, new best practices $400T – Dually Diagnosed Programming

4. What are your key strategic objectives?

Table 3 contains the strategic plan goals areas, core elements of the goals, and the deployment schedule for a three-year period. It cross references these elements to the key challenges for the agency, as identified in Section I.3. 5. Web access to the strategic plan The SCDMH homepage (http://www.state.sc.us/dmh/) includes a wide selection of key publications, including our strategic plan, bimonthly newsletter, quarterly mental health issues publication Focus, and others. Other homepage links are to consumer resources, clinical information, clinical services, career opportunities, and timely events and news.

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Category 3 – Customer Focus 1. How do you determine who your

customers are and what their key requirements are?

Our customer base is defined, in part, by legislative mandate and the South Carolina Code of Laws which give the Department jurisdiction over the state’s mental hospitals and community mental health centers. We receive our customers through their own volition, through family members, through the court system, and through law enforcement. We also seek out customers through embedded staff working in schools, other agencies, and hospital emergency rooms. To become a customer of the Department of Mental Health, one must have a diagnosable mental illness.

Our key customers are adults, children, and their families who are affected by serious mental illnesses and significant emotional disorders. These priorities were established by stakeholders through the strategic planning process and by the Clinical Care/Coordination Committee, a stakeholder group which assists the Department in program and policy development. DMH management and the Commission affirmed this decision, designated these groups of individuals as “priority populations” in its mission statement, and adopted the federal definitions of specific diagnostic categories for serious mental illness and significant emotional disorder. The key customer requirements for adults with severe mental illness have been defined by our consumers and the identified requirements are consistent with what is reported in the literature: regaining a sense of self worth and dignity; having a hopeful outlook on life; actively pursuing goals and aspirations in the areas of affordable housing, education, employment and social supports; and/or living a quality life. These requirements are operationalized as:

symptom reduction and functional improvement (Fig. 7.2-11); meaningful employment (Fig. 7.2-8 & 9); housing which is safe, affordable, and decent (Fig. 7.2-10); and satisfaction (Figs. 7.1-1 to 6).

Although recovery can begin or continue in inpatient care, the context of recovery is community based, and the Department is committed to a community-based system of care which meets the requirements of its consumers.

Recovery for children means increasing self-esteem, dignity, and school performance, remaining in their home, and working with the families to resolve issues and preserve the integrity of the family unit. These requirements are operationalized as: symptom reduction and functional improvement (Fig. 7.2-13); and parental satisfaction.

Promoting recovery in the child population requires working closely with the family and system collaborations with other agencies that are involved with the child and family.

2. How do you keep your listening and learning methods current with changing customer/business needs?

The Department believes that to promote recovery for people with mental illnesses, it is essential to have customers -- people with mental illnesses and their families -- involved in the planning, evaluation, and delivery of care. All major planning committees of the Department have consumers, family members, and advocacy organizations as representatives. Each CMHC has a Consumer Affairs Coordinator, a self-identified mental health consumer, who participates in management meetings and decision-making to provide a voice for the customer. Each CMHC and inpatient facility also has an advisory board composed of consumers of mental health services, and there is a statewide Consumer Advisory

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Committee operated by the Division of Healthcare Reform. As a standard practice in the Department, advocacy organizations review key plans, policies, and procedures prior to their completion. Once a month, the State Director holds a “Kitchen Cabinet” meeting with the primary advocacy groups to discuss improving our system of care, and advocacy groups are among those who attend monthly Assembly meetings and Commission meetings. To stay current on evolving health care service needs and directions, the agency also participates in national forums, has representatives on health care measurement task forces, and has senior leaders who hold offices in national bodies that help set the direction of health care delivery systems. A “Legislative Update” is published monthly during the legislative session to keep stakeholders, internal and external, aware of issues and events and their feedback to the agency offers insight into current perspectives on health care trends. Key staff are surveyors for major accrediting bodies which allow them to bring innovative approaches back to South Carolina and receive training in new approaches to service need assessment.

3. How do you use information from customers/stakeholders to improve services or programs?

The agency director and other senior leaders engage in “Listening and Learning” meetings with stakeholders at each of the 17 community mental health centers and participate in monthly conference calls with CMHC Board chairs to discuss priorities/concerns, community issues, and statewide issues. The Department has established a presence on the Internet and uses this medium to receive questions, concerns, and comments about the Department’s services. The

webmaster brings each of these to the attention of the Director of Behavioral Healthcare Services, as well as the State Director. ETV interactive broadcasts are used by the director as a means of communicating policy and direction and receiving feedback from consumers, advocacy groups, and employees statewide.

4. How do you measure customer/stakeholder satisfaction?

The Department collects data on a number of key indicators that reflect the customer perspective. We are a longstanding participant in the Mental Health Statistical Improvement Project (MHSIP), a 16 State Data Collection Project to develop national comparative data on customer perceptions of access to services, appropriateness of services, outcomes, and treatment planning involvement (Figs. 7.1-1 & 2). We are currently developing a standard process to measure both consumer and family satisfaction across all clinical components of the department.

The Department uses Consumer-to-Consumer Evaluation Teams (CCET) to evaluate and spur improvement in our system. These teams, composed of primary mental health consumers, interview other consumers on their perception of care, level of satisfaction, and ways to improve services. A written report is sent to the facility/center director, and directors have 90 days to develop a plan of correction to improve areas that have been identified by consumers as being deficient.

The Office of Consumer Affairs tracks each improvement plan and reports are made to the agency director. The Department’s consumer-driven evaluation system is a model program that has received national recognition.

DMH also determines customer satisfaction through annual satisfaction surveys conducted by each CMHC. CARF

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standards require consumer satisfaction measures, and all CMHC programs have been active with consumer evaluations since becoming accredited.

Because of the extent to which stakeholders are included in the fabric of the Department, stakeholder satisfaction levels are assessed more informally but more diligently than could be obtained through periodic surveys or questionnaires. In addition to participation in all policy and program development committees and task forces, the advocacy stakeholders identified in Section II are singled out for private meetings and discussions to address concerns and strategies for problem resolution. During the past year, the State Director’s calendar shows over 170 meetings, over and above committee and task force meetings, with these key stakeholders

5. How do you build positive relationships with customers and stakeholders? Indicate any key distinctions between different customer groups.

The culture of the Department is one of inclusion. Advocates, consumers, family members, and all stakeholders have an active place at the DMH table. The Department is definitive in its commitment that all stakeholders are an integral part of the state mental health service system, and a phrase used by Consumer Affairs Coordinators is indicative of the inclusive philosophy: “Nothing about us, without us.”

Advocacy organizations, involving families with mentally ill members, consumer groups, protection and advocacy groups, and other agencies are involved in the planning of services. Members from these groups are represented in the Clinical Care/Coordination Committee, one of the two primary DMH committees answerable to senior leadership, which advises and approves clinical policies and programs

Consumer focus groups indicated a desire for “Advance Directives,” instructions on level and type of care preferred by the consumer, made at a time when they were unclouded by the effects of their illness. The Department assists individuals in the preparation of these documents and actively supports their use. The Department actively encourages employees to participate in advocacy groups and stakeholder organizations at the state and local level. It believes in partnerships, each organization contributing to the effectiveness of the other. The Department has a client advocacy system with representatives in every hospital and community mental health center. These advocates ensure that consumers/patients are presented with their “bill of rights” during orientation, intervene on the behalf of consumers in complaint/grievance issues, and report complaints (resolved and unresolved) to facility/center leadership, DMH senior leadership, and the Commission.

Written responses to the complaint and the resolution are received by DMH administration, the consumer, and the S.C. Office of Protection and Advocacy. If the consumer is dissatisfied with the resolution, appeal procedures to the CMHC, facility, or State Director are available. The DMH Commission receives monthly reports on all complaints and resolutions. The Office of Consumer Advocacy reports that all consumer complaints for the past three years, inpatient and community, have been deemed resolved by the advocate.

Customer requirements are evaluated on a prescribed schedule: intake, at six month intervals if treatment is of longer duration, and at discharge. In short-term crisis facilities, the assessment is more frequent. The treatment plan is a living document that is updated regularly, based on the

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individual’s needs and customer expectations.

All CMHCs have self-identified mental health consumers as members of the management team, helping to ensure that management addresses issues and concerns with a consumer perspective. Inpatient facilities have Consumer Advisory Boards to assist facility management in addressing consumer care issues.

CMHCs will be hiring self-identified mental health consumers to assist with the delivery of care to other consumers. These peer support services are well-received by consumers and will assist Recovery for both the provider and the recipient of services.

We also have more routine avenues to receive consumer or family complaints, like letters, e-mail, suggestion boxes, and web access. One of the richest sources of useful information has been the Consumer-to-Consumer Evaluation Teams. The data that has been gathered by consumers having an informal, yet structured, discussion with a fellow consumer has been an eye-opening, rewarding experience for our Department. Category 4 – Information and Analysis 1. How do you decide which operations,

processes and systems to measure? The Department's management information system includes an integrated database consisting of data on all consumers served by its hospitals and mental health centers. This includes demographic and clinical data on consumers, service utilization, expenditures, event data, human resource data, and operational costs (Figure 4.1-1)

At the Department level, decisions about which operations and/or processes to measure are made by the senior leadership and affirmed by the DMH Commission. At the division, center and facility level, the manager may make decisions on additional

data elements to collect and aggregate to help track daily operations. Candidate indicators are proposed because of their impact on the system, utility for clinical decision-making, and the relative ease of collection.

Key processes and key measures in the public mental health system, however, are an evolving science, and there is never an assumption that the measures used to assess a process are sacrosanct. Two criteria have governed our decision to select the process or operation for measurement: high resource use (cost) and/or clinical impact (high levels of restrictiveness or risk). Consumer requirements provide the underpinnings for these criteria.

Clearly, the Department chooses to measure program performance and consumer outcomes in areas identified as priorities in the Community Development Plan (Figs. 7.1-1 through 5, 7.2-2, 4, 5, 6, 8, 9, 10, 11, 13, & 15). These are the services and programs most important to the stakeholders. For our inpatient system, many of our performance measures are mandated by accrediting bodies. A measurement system called ORYX, from JCAHCO, gives us the

Clinical Intake Info

Service Utilization

Data

Dashboard Indicators

Continuity of Care

Standards

Risk Mgmt, QA, PI,

Event Data Integrated Data Base

Human Resource Info

Financial

Figure 4.1-1

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ability to compare DMH inpatient facilities with other public mental health facilities nationally on key performance measures such as readmission rates and the use of seclusion and restraints (Figs. 7.2-17, 18, & 19). DMH leadership reviews this comparative data monthly and South Carolina has volunteered to be a pilot site for the development of national normative outcome data sets for the ORYX community mental health system.

2. How do you ensure data quality, reliability, completeness and availability for decision making?

A new client information system was implemented in the fall, 2001 and is the backbone of all client information for the agency. Data on active clients from the previous system rolled forward into the new system, which provides individual data sets on current consumer information, allows managers to monitor program performance, and provides administrators with decision-making tools to manage by fact. A master patient index (MPI) was established at the same time which tied the inpatient and outpatient billing and registration systems together and resulted in a major reduction in duplicate client identifiers and facilitated the tracking of consumers across all service programs.

In partnership with our Division of Financial Services, the IT Division implemented Phase I of SAP Financials on November 1, 2002. The new system, with DMH as the pilot SAP site for state agencies, decentralized purchasing and accounts payable to CMHCs and hospitals. All organizational component sites were upgraded to T-1 communication circuits, providing improved performance support for SAP and the web based applications, such as SAP Imaging, report2web, pharmacology on-line, and telepsychiatry.

Data and reports are requested on a regular basis by Governing Council and used in priority setting and decision making. Centralized data is compiled on a weekly, monthly, quarterly, and yearly basis and is disseminated on the Department’s internal (Intranet) website and through various publications. The objective is to provide the right information to the right people at the right time to improve consumer care and organizational performance.

A report generating software package is made available to clinicians and managers system-wide and canned or customized reports generated from the integrated database. Reports can be obtained on any variable, or combination of variables, as delineated in Figure 4.1-1.

Access to the Department’s data base is strictly monitored and controlled. Authorizations must be provided through supervisory channels, and all programs are password protected. Patient confidentiality has always been a priority for the Department. New employees receive extensive training in this area and must sign a “Confidentiality of Medical Information” form prior to patient contact. To ensure that data is accurate and reliable, computer programs assess the completeness of data elements. All computers have anti-virus software to screen incoming data and monitor the network systems. IT backs up all critical files on prescribed schedules and has disaster recovery capabilities according to industry standards. The entire DMH data communication network sits behind a Check point firewall to protect against intruders. DMH also uses 128 bit encryption to protect DMH e-mail access. IT monitors all network devices (routers, switches, servers) for reliable and continuous connectivity.

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The IT Division maintains a hotline for reporting problems with hardware and software, and each organizational component has a Systems Administrator with designated responsibilities for installing new software, trouble-shooting the existing system, and securing appropriate training for division staff.

3. How do you use data/information analysis to provide effective support for decision making?

The basic dashboard (Table 2, Measures of Organizational Effectiveness and Efficiency) contains an analysis of both trend and comparative data across time and against standards. These, combined with the risk management analysis described in Category 6, provide managers with measures on key customer requirements for customer groups, program effectiveness, and program efficiency.

The dashboard indicators are distributed to key staff and stakeholders and are published on the Department’s Intranet, and the monthly ORYX inpatient outcomes are distributed to facility directors. Management staff at CMHCs, facilities, and the administration produce reports of their choosing from a large selection of “canned” programs on financial, human resource, and clinical performance of the agency.

Best Practice Programs are measured for fidelity to the model, since research indicates that key factors such as staffing patterns, service configuration, and treatment regimen equate to treatment outcomes.

Strategic Plan accomplishments are monitored and reported quarterly. Each goal contains due dates for program development milestones. Strategic Plan program development also contains key requirements for program success, e.g., satisfaction measures, clinical outcomes, and consumers

employed. Quarterly updates on strategic plan activities and goal accomplishments are given at stakeholder Assembly meetings and Commission meetings.

4. How do you select and use comparative data and information?

For several years, we have participated in a federal grant that has developed a core data-set for our community system of care. This data-set includes measures of utilization and penetration as well as consumer satisfaction.

Since each state has different definitions for populations served and state vs. private facility inclusion (Figs. 7.2-1, 12 & 14), it has been difficult to find comparative utility in these measures,. We continue our participation because the development of national norms and benchmarks is a priority for DMH leadership, and working through multi-state cooperatives appears to be our most productive avenue.

The Department also has a committee currently examining the ongoing utility of our consumer outcomes and satisfaction instruments and has performed a comprehensive review of professional literature assessing the strengths and weaknesses of the different approaches.

Category 5 – Human Resources 1. How do you and your

managers/supervisors encourage and motivate employees (formally and/or informally) to develop and utilize their full potential?

All job positions require written descriptions of duties, needed skills, and educational requirements. Staff are recruited and hired based upon these criteria and senior leadership and program managers fully understand that the retention of valued employees is cost effective as well as sound business.

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Job classifications and assignments are designed to support service delivery and the needs of the agency’s consumers. While the concept of Treatment Teams has always been the norm in mental health treatment, Best Practice programs like ACT/PACT Teams have made treatment teams a science. In addition to the benefits received by the consumers, the team concept carries a strong motivating force for job enrichment.

EEO/Affirmative Action data indicate that the Department ranked eighth in large state agencies in meeting its affirmative action goals. During the past year the percentage action goals met increased from 83.9% in 2002 to 87.5% in 2003.

The Department’s use of flex-time, especially has been welcomed by employees and has allowed CMHCs to expand the hours of operation and improve customer service by providing appointments outside of normal working hours. The Department also has a tuition reimbursement program, which allows employees to be reimbursed for classes that are helpful to his/her current job performance or to prepare the employee for other positions within the Department.

Other innovative means that employees report as motivating or encouraging include: Job Sharing to accommodate employee needs while still accomplishing the mission of the office; Cultural Action Center training of staff to assist them in providing culturally sensitive services to our clients; staff meetings with the State Director to keep employees informed about what is happening in the Department and to answer questions that the staff may have; and development of best-practice models which allow employees to work in state of the art programs. In addition to the standard state agency Outstanding Employee Award Program which recognized 22 employees for their performance, the Department had 28 other

organized recognition events during FY 03, with a total of 264 individuals receiving special recognition.

2. How do you identify and address key developmental and training needs, including job skills training, performance excellence training, diversity training, management/ leadership development, new employee orientation and safety training?

Agency priorities and training beyond the expertise of individual units are conducted by the Division of Education, Training and Research (ETR). While the agency’s training plan is driven by the strategic plan and accrediting body standards, ETR has a Training Council for policy/priority setting. At the individual level, training and development needs are an integral part of annual employee evaluations and planning stages for the next year.

A formal training needs assessment of all staff was conducted in April 2002 to ensure that clinical and support staff receive training and learning experiences which support the goals, objectives and performance expectations of DMH.

Opportunities for training are advertised through course catalogs published twice a year and daily e-mail announcements. Staff, in consultation with their supervisor, register for training through the Department’s Intranet training management system (Pathlore), which tracks all classes to be held, enrollment, and completed training.

One hundred percent of new employees received a general and a job specific orientation upon hire. All employees receive updates annually, specific to their facility/center, and the Department has a 100% compliance with these requirements.

The Department has implemented Computerized Learning Modules (CLMs),

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designed to improve employee training and save taxpayer dollars. The CLMs bring training to the employees’ workstation, enhance knowledge, reduce travel time and costs, provide consistency of instruction, and provide a more responsive training development and deployment system. The estimated cost savings for these ten modules was $500,000 and more savings will be realized as additional modules are developed. All CLMs have been developed in-house, realizing additional cost savings.

The Department also utilizes traditional approaches to staff education and training - classroom instruction and the state’s educational television system. In addition, the agency offers specific training for employees to prepare them for professional license exams and license renewal. Figure 73-1 provides the type of training, attendance and hours, and measurement systems used by DMH to prepare/retain its workforce.

3. How does your employee performance management system, including feedback to and from employees, support high performance?

All staff receive performance evaluations at least annually based on a set of performance criteria jointly agreed to at the start of the year by both employee and supervisor. The criteria are specific to job descriptions which are written to conform to programmatic needs and customer requirements.

The employee and the supervisor are encouraged to meet at least once during the rating period to discuss the employee’s performance and to identify problems that are preventing the employee from meeting his/her success criteria.

4. What formal and/or informal assessment methods and measures do you use to determine employee well being, satisfaction, and motivation?

The State Director has taken a personal interest in communicating the agency’s priorities and reaffirming the Department’s commitment to its employees during these difficult economic times. He has visited each of the state’s 17 mental health centers and the inpatient facilities twice in the past two years to speak with staff, learn their concerns, and keep them updated. He maintains an “open-door” policy, e-mail accessibility, and conducts quarterly “all-hands” meetings to discuss the state of the agency.

The Department’s Communication Office maintains a Hotline that allows employees to ask questions about policies and procedures or rumors. This Hotline allows the Department to get accurate information to its employees.

5. How do you maintain a safe and healthy work environment?

In addition to the employee benefits package of health, life, and dental insurance, the Department takes full advantage of the health and safety inspections provided by the numerous accrediting bodies who survey each of our community mental health centers and our inpatient facilities. The Department has received no violations in any recent survey.

Additional initiatives in this area include: • safety training for staff and safety

inspections of all facilities; • Fire/Safety Committees composed of

employees and fire/Safety Officers; • pre-employment tuberculosis testing of

employees, annual employee health screenings and annual Employee Health Clinic free flu shots;

• annual wellness related activities; • air quality and hazardous chemical

inspections of buildings; and • inspections by quality assurance teams,

Internal Audit, and Public Safety.

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There is a health clinic available that, in addition to caring for and tracking work related injuries, provides immunizations, vaccines, and blood pressure reading.

6. What is the extent of your involvement in the community?

In May 2000, DMH launched an Anti-Stigma Campaign to raise public awareness about mental illness and reduce the stigma associated with the disease. Some highlights of the past year include: • Radio public service announcements were

sent to 18 stations statewide; • The Art of Recovery project, showcasing

the artistic skills of people who receive care from DMH, has featured over 200 works from more than 200 artists;

• A Palmetto Media Watch Program was organized which gives feedback to the media on coverage of mental health isues;

• A Teen Matters website for teenagers; • A Million Mile Walk, initiated last year, in

which 2,000 people walked 1,000,000 miles to show their support of people who have a mental illness;

• DMH’s Speaker’s Bureau made over 100 presentations to civic and community groups; and

• DMH staff made 469 presentations to schools, 78 presentations to civic groups, and 92 presentations to churches.

Category 6 – Process Management 1. What are your key design and

delivery processes The design of services is based upon “best practice” or “evidence-based” technology. Quite literally, the Department constructs programs based upon the reported results from research studies in the mental health field, making the agency’s design process a “Science-to-Practice” methodology. These Best Practice programs (identified in Table 1) are the priorities identified in our strategic plan and the agency’s budget request.

Best Practice Programs, by definition, include efficiency and effectiveness factors in their design process (Figure 6-1). Outcomes are put into place on the front end, allowing for service designs which focus on cost control, productivity, and customer satisfaction. With outcome measures of key program and customer requirements part of program design, all programming includes requirements of accrediting and regulatory bodies.

Patient’s expectations are central to our individualized treatment plan, in which needs, requirements, and preferences are clearly recorded and incorporated into a regularly updated plan. These expectations are re-confirmed for new patients during the patient rights orientation process.

Consumer/ Stakeholder

Input

Strategic Plan

Priorities

Select Best Practice Model(s)

Program Sites Initiated

Confirm Fidelity

to Model

Outcomes Meet or Exceed Consumer/ Stakeholder

Requirements

Program Sites Expanded

Program Sites Become Teaching Centers

Program Monitoring: Compare Data Between Sites,

Against National Standards, Against Fidelity Standards

Selection and Implementation of Best Practices

Feedback into Planning Cycle

Figure 6-1

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2. How does your day-to-day operation of key production/delivery processes ensure meeting key performance requirements?

Day-to-day operations are governed by our Continuity of Care Standards, QA requirements, accreditation standards, Medicare contracts, and the program standards dictated by adherence to best practice models. Departmental policies and procedures conform to, or exceed, all requirements of regulatory agencies and accreditation bodies.

The Department monitors daily the electronic transactions between hospital and centers on discharge information of consumers with same day corrective actions initiated on any errors noted. Monthly reports are made on facility compliance with sending Continuity of Care (COC) electronic data to centers within 24 hours of patient discharge. Monthly reports are also made on center compliance with COC electronic data confirming follow-up activity post discharge

The overall quality system for the Department operates under a dual system of assessing adherence to standards (retrospective) and process improvement (prospective). All of our service processes are defined, measured, and managed through these two systems and are underpinned by the accreditation standards of JCAHO and CARF, which constantly monitor our service delivery processes to ensure we provide the highest quality of services.

The elements of accreditation standards are made operational through policy documents, the Continuity of Care Standards Manual, Case Record Reviews, QA, local and state office level audits, Corporate Compliance audits, risk management system, and utilization review. Our standards are frequently higher than those set by accrediting bodies, and never lower. All

facilities of the Department, community and inpatient, are fully accredited by accrediting bodies.

While these mechanisms are the formal system to ensure that processes meet key requirements, the heart of the system is the relationship between the clinical staff and the consumer. There is an active partnership between the treating team of professionals and the persons we serve. The process is a customer-driven contract between the Department and the consumer.

In addition to front-end performance improvement efforts and back end quality assurance audits, the Department has a comprehensive Risk Management Information System which tracks all “adverse incidents” in the Department. The State Director receives daily reports on the details of all serious events

The event investigations are tracked, and a determination is made whether to initiate a Quality of Care Review Board (QCRB) to assess the root cause of the occurrence and make recommendations for corrective actions (Figure 7.2-20). All QCRB recommendations are tracked, and learnings from one part of the system are applied to all other appropriate components.

3. What are your key support processes, and how do you improve and update these processes to achieve better performance?

Key support processes, key requirements, and performance level of these processes are presented in Table 6-2

Support processes are managed by the Deputy Director of Administrative Services, a member of Governing Council and chair of the Business Committee. All process improvements for this area are coordinated through monthly meetings of the Business Committee.

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.During the past two years the Department has replaced its legacy reimbursement and financial information data processing system with state-of-the-art software. The new system provides a fully integrated process with real-time transaction processing by service delivery areas throughout the agency’s network. Financial management data is available with real-time access. The software was configured to perform functions specified by end users.

4. How do you manage and support your key supplier/contractor/partner interactions and processes to improve performance?

All contracts are coordinated by the Contracts Office. Key performance requirements involve timely review and approval of contracts. All contract information is entered into the agency’s new financial system (SAP), which is available to users and provides information on all professional service contract services. Additional information concerning leases and other data not in the system is also maintained by the Contracts Office. Approximately 1,250 contracts and memorandum of agreements are tracked and monitored by a Contract Monitor who is responsible to insure that all provisions of the agreements are met.

Table 6-2 Key Support Processes Process Key Requirements Status

Accounting Reconciliations with state accounting system (STARS) are performed in accurate timely manner

Reconciliations are running behind due to staff turnover and change to new accounting system. DMH/ and CG are investigating automated reconciliations.

All invoices submitted for payment shall be processed in no more than 3 business days

Process is within the 3 day goal

No significant audit findings as a result of the Agrees Upon Procedures Audit by State Auditors

No findings currently

Procurement Process procurement request up to $10k within 5 working days; between $10k and $25k within 15 working days; and above $25 k within 28 working days

Goals are being met

Contracts Reduce the no. of days to process contracts from 8 to 6 Average processing time is 3.5 days Reduce the number of sole source contracts by 10% Contracts reduced by 10.8%

Information Tech

To maintain staff quality by maintaining turnover below 15%

Staff turnover is below 15%

Complete HIPAA transactions and codes for inpatient and outpatient by October 2003

Tested 837 transactions and codes with Medicare.

Nutritional Services

Provide meals daily which are nutritious, appetizing, & satisfying for all consumers as required

Satisfaction surveys completed

Provide equipment, facilities, staff and food which meet all regulatory agency standards

All facilities in compliance by DHEC, JCAHO & CARF, VA and HCFA

Maximize sale of excess food preparation capacity to other entities.

Gross sales of $1.7 million in food netted DMH $133,000 in FY 03

Physical Plant

Insure that all capital projects are completed within approved budgets

All completed projects were within approved budgets during FY 03

Vehicle Management

Insure that all vehicle and equipment repairs are conducted in the most cost efficient manner

Performed 1,558 repairs to vehicles and equipment saving $8,900 as compared with vendor list prices

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7.1 What are your performance levels and trends for the key measures of customer satisfaction? Consumer Perception of Care Data: For several years the Department has participated in the 16 State Performance Indicator Project, developing comparative measures of mental health performance data. One instrument used by the project is the MHSIP Consumer Survey, which assesses customers on three domains: Satisfaction with Access to Care; Perceived Quality of Care; and Satisfaction with Treatment Outcomes (Figure 7.1-1).

16 State MHSIP Satisfaction Survey

0%10%20%30%40%50%60%70%80%90%

100%

Access Quality Outcome

FY 01 FY 02 FY 03 16 State Avg Figure 7.1-1 (Higher is Better)

The results are presented as a percent of the respondents that agree or strongly agree to the items in each of the domains. While the final data sets are still emerging as the utility of each measure becomes established, the development of normative data is a priority at the national level and within SC. The Rural Behavioral Health Services (RBHS) Program, a rural ACT program, is evaluated using the MHSIP Consumer Survey (Figure 7.1-2).

Rural ACT ServicesConsumer Satisfaction Survey

0%

20%

40%

60%

80%

100%

Access Quality Outcome Involvement16 States Low 16 States High S.C. DMH

Figure 7.1-2 (Higher is Better)

The consumer ratings of satisfaction are equal to, or better than, the optimal levels achieved by other states in the domains of Access to Care; Perceived Quality of Care; Satisfaction with Treatment Outcomes; and Involvement in Treatment Planning.

Consumer to Consumer Evaluation: This consumer driven process involves current or former mental health consumers who interview current consumers, asking both open- and closed-ended questions about satisfaction with services being received.

Consumer-to-Consumer Evaluations indicate that DHM has made progress in increasing consumers’ involvement in designing their own treatment plan, that they are more aware of the availability of after-hours emergency services, and we are better able to meet their need for more information about their medical condition. (Figure 7.1-3)

Consumer SatisfactionConsumer-to-Consumer Evaluation

0%

20%

40%

60%

80%

ITP Participation Wants MoreMed. Info.

Aw are ofAfter-HoursEmerg. SrvsFY00 FY01 FY02

Figure 7.1-3 (Higher is Better for “ITP Participation” and Aware of After-Hours Emergency Services.” Lower is Better for “Wants More Medical Information.”) The survey is under revision, so no data is available for FY 03.

TLC Program Consumer Satisfaction: Consumers in the TLC Program have been long-term residents of inpatient facilities. It is critical that their community living arrangements be appropriate and that they receive intensive case management services.

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The majority of TLC clients, about 70%, report that their living situation is satisfactory (Figure 7.1-4). Only a very small percentage indicates a desire to return to the hospital

TLC Consumers: Satisfaction With Living Arrangement

0%

20%

40%

60%

80%

100%

Satisfied Want Hospital

1999 2000 2001 2002 2003 Figure 7.1-4 (Higher is Better for “Satisfied”; Lower is Better for “Want Hospital”)

When asked to evaluate their “Quality of Life,” TLC consumers consistently reported higher scores after becoming part of the program (Figure 7.1-5). Pre/Post scores are statistically significant at the p< 0.001 level.

TLC Consumer's Quality of Life Survey

4.4

4.6

4.8

5

5.2

5.4

1999 2000 2001 2002 2003Before TLC In TLC

Figure 7.1-5 (Higher is Better)

Clearly, the intense services received by TLC consumers make a dramatic difference in how they perceive their world. As they feel better about their quality of life, their mental status, self-concept, and well-being improve, which serves to impact positively their recovery.

TLC clients were asked how they feel about the mental health services they receive and the mental health staff (Figure 7.1-6). On a range from 1-7, with 1 being Terrible, to 7 being Delighted, TLC clients report that they are “mostly satisfied” and “pleased” with mental health services and with the staff providing those services.

TLC Client Satisfaction

55.25.45.65.8

66.2

Satis. with Services Satis. With Staff

2000 2001 2002 2003

Figure 7.1-6 (Higher is Better)

7.2 What are your performance levels and trends for the key measures of mission accomplishment? Penetration Data: A community-based system of care is core to the Department’s philosophy and has been a driving force in program development through the past three strategic plans. South Carolina’s CMHC penetration rate reflects the Department’s success in reaching persons in need of services.

DMH is currently the third highest in penetration rate of the states participating in the 16 State Performance Indicator Project (Figure 7.2-1). The next national data sets will be available to states in 2004.

Rate Per 100,000 Served by CMHCs: FY 00

0

1000

2000

3000

4000

TX CT OK MO IL IN VA CO DC AZ UT WA SC RI VT

Figure 7.2-1 (Higher is Better)

Services in the Community: For a number of years, DMH has placed a priority on expanding its community-based system of care. This growth in the number of persons served from FY 99 through FY 01 is shown in Figure 7.2-2 and parallels the decrease in hospital admissions (Figure 7.2-15).

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Number of People Served in CMHCsUnduplicated Count

76,000

80,000

84,000

88,000

92,000

96,000

FY 98 FY 99 FY 00 FY 01 FY 02 FY 03

Figure 7.2-2 (Higher is Better)

The 3% decrease in FY 02 and the 1% decrease in FY 03 reflect the impact of budget reductions on service expansion. With fewer resources and an impaired ability to expand services to a greater number of persons, DMH chose to focus its limited resources on its priority populations: adults and children with major mental illnesses. As shown in Figure 7.2-3, total clinical contacts increased by 1.5% in FY 02 and 4% in FY 03.

CMHC Clinical Contacts

1,500,000

1,600,000

1,700,000

1,800,000

1,900,000

FY 98 FY 99 FY 00 FY 01 FY 02 FY 03

Figure 7.2-3 (Higher is Better)

This focus on priority consumers is further evidenced in Figure 7.2-4 which shows the expansion of clinical contacts with individuals diagnosed with a major mental illness.

Consumer Contacts with Major Mental Illness, as Percent of Total Contacts

77%

41%

79%

45%

80%

45%

0%

20%

40%

60%

80%

100%

Adults Kids

FY 01 FY 02 FY 03

Figure 7.2-4 (Higher is Better)

This means that the Department focused its limited resources on its priority populations, actually increasing the quantity of services provided to them.

TLC Outcomes: The TLC program has a ten-year history of transitioning residents from long-term care psychiatric inpatient facilities to living in the community.

Participants in the TLC program receive intensive support through the Community Mental Health Centers, helping them adjust to community life and secure daily living skills.

The TLC Program provides intensive case management services to persons with three or more admission per year, assisting them to reduce their use of hospital care.

Over 1,100 severely mentally ill mental health consumers have participated in the TLC program, moving from institutional care to community life. Figure 7.2-5 shows the parallel between long term psychiatric inpatient census and TLC program expansion.

TLC Capacity and Utilization of Long Term Inpatient Facilities

0

200

400

600

800

1000

92 93 97 98 00 01 02 03TLC Capacity Long Term Psych. Census

Figure 7.2-5 (Higher is Better for TLC Capacity; Lower is Better for Long Term Psychiatric)

For TLC program participants there is a 90% reduction in the total number of hospitalization days per year (Figure 7.2-6). When TLC program participants are admitted to an inpatient facility, the length of stay in the hospital is markedly shorter.

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Reducing Hospital Recidivism

151

373

21 160

100

200

300

400

Days Per Admit Days Per Year

Pre-TLC In TLC

Figure 7.2-6 (Lower is Better)

Consumers are assessed for both symptom reduction and functional improvement. Clients of the TLC program experience fewer depressive and psychotic symptoms, while improving slightly with social acceptability (Figure 7.2-7). Given that the clients are long term institutionalized individuals, these numbers represent improvement in a slow and gradual process with their acclimation to the community.

TLC ConsumersSymptom Reduction/Functional Improvement

0

10

20

30

40

Depression Psychosis SocialAcceptability

Baseline

End Point

Figure 7.2-7 (Lower is Better for Depressive and Psychotic Symptoms. Higher is is Better for Social Acceptability)

Consumer Quality of Life: Consumer recovery is closely tied to quality of life indicators. Consumers want productive employment and housing that is safe, affordable, and decent. These two factors, housing and employment, are major contributors to a consumer’s transition from a life of dependency on the mental health

system to a life of independence and self-reliance.

DMH has hovered at the national average for the past four years in its efforts to improve the employment rate for severely and persistently mentally ill consumers (Figure 7.2-8). After showing steady progress for five consecutive years, budget and staff reductions have begun to affect employment progress and are apparent in 2002.

DMH ConsumersPercent Employed

0%

4%

8%

12%

16%

20%

1999 2000 2001 2002 Nat.AvgLow

Nat.AvgHigh

Figure 7.2-8 (Higher is Better)

DMH uses Job Coaches to assist consumers in securing and maintaining employment which is gainful and meaningful. FY 01 to FY 02 showed a 15% increase in the number of successful placements.

Consumers Placed by DMH Job Coaches

730

837

650

700

750

800

850

2001 2002

Nu

mb

er

of C

on

sum

ers

Figure 7.2-9 (Higher is Better)

28

The Department’s Housing Program for severely and persistently mentally ill consumers has shown major advances since inception (Figure 7.2.10). Working through federal grants and partnerships with the Housing Authority and the Mental Health Association, the Department receives a 400% match for every dollar invested in housing development.

Housing for ConsumersNumber of People

0

200

400

600

800

1000

1200

1400

90 91 92 93 94 95 96 97 98 99 00 01 02 03

Cum

ulativ

e

Figure 7.2-10 (Higher is Better)

Symptom Reduction and Functional Improvement: Adults. Consumers are clinically assessed at admission and at discharge with a self-administered instrument called the BASIS 32, which rates the individuals’ level of symptoms and their ability to apply everyday life skills.

The higher the score on the BASIS 32, the more severe are the symptoms and the poorer the daily living skills. Consumers who continue to receive services for extended periods may receive any number of “mid-treatment” assessments.

Consumers achieve a significant amount of improvement from admission to mid-treatment assessment, with a change score of about 40% as measured by the BASIS 32 (Figure 7.2-11).

With seriously mentally ill consumers, there is a leveling out of improvement after the initial reduction in the severity score. Even so, between the mid-treatment assessment and discharge, scores drop another 25%.

BASIS 32 Total Score

0.0

0.5

1.0

1.5

2.0

FY 99 FY 00 FY 01 FY 02 FY 03

Admission Mid Tx Discharge

Figure 7.2-11 (Lower is Better)

There has been a slight increase in the admission scores over the last few years, possibly a reflection of the Department’s focus on more severely impaired consumers. While mid-treatment scores are holding constant, discharge scores are also showing a slight improvement.

Symptom Reduction and Functional Improvement: Children. DMH has increased its focus on providing services to children and adolescents. Sixteen-State Study penetration data (Figure 7.2-12) shows that we are only exceeded by Vermont in rate per 100,000 children served.

Under 18 Years Old Served by CMHCs Rate Per 100,000 Served

0100020003000400050006000

OK TX MO IL IN DC VA AZ UT WA CO RI SC VT

Figure 7.2-12 (Higher is Better)

Like adults, children and adolescents are clinically assessed at admission and discharge. The treatment duration for these consumers is usually briefer, so mid-treatment assessments are less common.

Our child clinical instrument is the CAFAS, which assesses the child’s psychiatric symptoms as well as functional abilities in school, at home, with peers, and in society.

29

Of the four CAFAS scoring categories (Minimal, Mild, Moderate and Severe), the Moderately and Severely Impaired individuals meet the DMH definition as a priority population: severely emotionally disturbed.

Figure 7.2-13 shows the degree of improvement for these children following treatment. Over sixty percent of the children improve their CAFAS scores. About 44% show a significant improvement, moving at least one category level.

CAFAS: Moderate and SeverelyImpaired Children

0%

20%

40%

60%

80%

FY 00 FY 01 FY 02 FY 03

Cum

ulat

ive

% Significantly Improved % Improved

Figure 7.2-13 (Higher is Better)

Inpatient Services: Comparative 16 state study data show that the penetration rate for S.C. state psychiatric hospitals continues to be high when compared to other states (Figure 7.2-14), indicating an over-reliance on hospitalization as a standard care option.

Rate Per 100,000 Served by Hospitals

0

100

200

300

400

500

AZ UT IN VT RI CT CO NY TX WA IL VA OK MO SC DC

Figure 7.2-14 (Lower is Better)

This high use of inpatient facilities may reflect, in part, our history of relying on a centralized hospital system, but they also demonstrate major differences in how public mental health systems are organized and how the data are reported.

Most states have a much better developed hospital system that is not operated by the state. Since they do not report admissions to these non-state operated facilities, their inpatient admission rate appears much lower.

Further, since DMH is the primary provider of inpatient psychiatric care for the indigent and persons involuntarily committed (98% of all acute care admissions) South Carolina’s hospitalization rates look e xceptionally high.

As our community-based system of care grows, we are better able to support persons in crisis without hospitalizing them. Figure 7.2-15 shows the decreasing admission rate of hospital admissions and is in keeping with our goal of reducing our dependence on expensive inpatient care.

Psychiatric Hospital AdmissionsPer 100,000 Population

0

50

100

150

200

250

FY 98 FY 99 FY 00 FY 01 FY 02 FY 03

Figure 7.2-15 (Lower is Better)

During FY 03 acute admissions to DMH inpatient psychiatric facilities were decreased 21%. This follows a 29% decrease in FY 02, a 15% decrease in FY 01 and a 10% decrease in FY 2000.

In reducing its own use of inpatient care, DMH has not shifted the burden and expense of inpatient care to non-DMH hospitals.

The number of hospitalizations to non-DMH operated facilities has remained constant, even with the planned decline in DMH admissions (Figure 7.2-16). These figures lend support to the effectiveness of DMH in providing appropriate community support for

30

consumers to avoid unnecessary hospitalizations.

Hospital Admissions

0

200

400

600

800

1000

1200

7/00 11/00 3/01 7/01 11/01 3/02 7/02 11/02 3/03

Non-DMH DMH

Figure 7.2-16 (Higher is Worse)

Inpatient Performance Measures: Senior leadership reviews key performance data monthly for each inpatient facility. The measures include 30-day readmission rates, restraint hours, and seclusion hours.

30-Day Readmission Rate: Percent of admissions to facilities that occurred within 30 days of a previous discharge of the same client from the same facility. For example, a readmission rate of 8.0 means that 8% of all admissions were readmissions.

Figure 7.2-17 shows that DMH is consistently below the national average readmissions within 30 days of discharge.

30 Day Readmission Rate

0.00

2.00

4.00

6.00

8.00

10.00

9/01 11.01 1/02 3/02 5/02 7/02 9/02 11/02 1/03

National Rate DMH Rate

Figure 7.2-17 (Lower is Better)

Restraint Hours: The number of hours that clients spend in a physical restraint for every 1000 inpatient hours. For example, a rate of 1.6 means 2 hours were spent in restraint for each 1250 inpatient hours. Figure 7.2-18

compares the hours of restraint used at DMH facilities to the national average.

DMH hovers around the national average on this measure.

Restraint Hours, Per Patient

0.00

1.00

2.00

3.00

4.00

9/01 11.01 1/02 3/02 5/02 7/02 9/02 11/02 1/03

National Rate DMH Rate

Figure 7.2-18 (Lower is Better)

Seclusion Hours: Number of hours spent in seclusion for every 1000 inpatient hours. For example, a rate of 0.8 means that 1 hour was spent in seclusion for each 1250 inpatient hours. Figure 7.2-19 compares the hours of patient seclusion used at DMH facilities to the national average.

The national average appears to be dropping as DMH fluctuates around .5 hours, per patient.

Seclusion Hours, Per Patient

0.00

0.40

0.80

1.20

9/01 11.01 1/02 3/02 5/02 7/02 9/02 11/02 1/03

National Rate DMH Mean Figure 7.2-19 (Lower is Better)

Adverse Event Data: The Department has a well-defined system to actively track and report significant adverse events that occur anywhere in the agency, and senior leadership uses the data to correct deficiencies in the system and to prevent the reoccurrence of undesirable events.

31

There are 69 categories of incidents whose occurrence are tracked and reported to the Risk Management Office. A daily report is provided to the agency director detailing any event and actions being taken, whose significance level exceeds a standard.

When an incident indicates a failure in the system, a Quality of Care Review Board (QCRB) is established to determine the root cause(s) of the incident and make recommendations to prevent its reoccurrence. One year after the recommendations are made, the agency conducts an audit to determine the degree to which the recommendations were implemented.

Figure 7.2-20 supports the seriousness with which the agency takes QCRB recommendations, with over 94% of the recommendations having been implemented. The gradual reduction in the number of significant events in the years reported is consistent with quality management literature: as the most difficult incidents are corrected through root cause analysis and the system becomes more quality oriented,

the overall number adverse incidents decreases.

Figure 7.2-21 shows trend data on one risk management category. The risk management office collects information on any person who is injured by falling, an event of increased probability for elderly or infirmed persons residing in a nursing home.

Falls With Serious Injury

20

40

60

80

100

120

2000 2001 2002Calendar Year

Num

ber o

f Fal

ls

Actual Expected

Figure 7.2-21 (Lower is Better)

“Actual” is the number of events documented. “Expected” is the national average for similar facilities adjusted to match the size of DMH facilities. DMH has significantly fewer “Falls with Serious Injury” than the national average.

Figure 7.2-20 Quality of Care Review Boards

Calendar Year

No. of Significant Incidents

No. of QCRBs

No. of QCRB Recommendations

% of Recommendations Implemented *

95 628 32 98 100%

96 626 33 78 100%

97 662 34 78 90%

98 576 26 93 95%

99 523 24 68 100%

00 483 12 36 92%

01 381 22 127 85%

* Based on audit 12 months after recommendations were accepted. Some recommendations may take longer than 12 months to fully implement across the system

32

Other data sets, such as Continuity of Care, are reviewed monthly by senior leadership and the Commission. Continuity of Care research indicates that the sooner a person is seen by the community mental health center following discharge from an inpatient facility, the less likely the consumer will be readmitted for subsequent inpatient care.

Days Between Inpatient Dischargeand CMHC Appointment

4.44.85.25.6

66.46.8

FY '98

FY '00

FY '02

July

'02

Sept. '

02

Nov. '0

2

Jan,

'03

Mar. '0

3

May '0

3

Day

s

Figure 7.2-22 (Lower is Better)

The steady rise in the number of days from discharge to CMHC appointment in FY 99 and into FY 02 (Figure 7.2-22) is an undesirable trend, causing the Department to initiate improvement activities. The quality improvement intervention reduced the number of days between inpatient discharge and follow-up appointment at local CMHCs. The FY 02 average is 6.5 days. The March-May 2003 average is leveling off at about 4.8 days.

When the number of persons waiting in jail for Pre-Trial psychiatric evaluation began to rise in July, 2002, DMH leadership initiated a quality team to restructure the admission and evaluation process. Figure 7.2-23 shows the number decreasing from a high of 62 in September, 2002 to 9 in June, 2003.

Pre-Trial Waiting List

010203040506070

J 02

M 02 M 02 J 02

S 02N 02 J 0

3M 03 M 03

Figure 7.2-23 (Lower is Better)

Similarly, in March, 2002 there were 18 persons waiting in jail for admission to inpatient treatment who had been adjudicated Not Guilty by Reason of Insanity or Incompetent to Stand Trail. DMH leadership initiated a quality improvement team to reduce the waiting time. Figure 7.2-24 shows the number decreasing from a high of 18 in March, 2002 to 3 in June, 2003.

Psychosocial Rehabilitation ProgramWaiting List

0

5

10

15

20

M02

A02

M02

J02

J02

A02

S02

O02

N02

D02

J03

F03

M03

A03

M03

J03

Figure 7.2-24 (Lower is Better)

7.3 What are your performance levels and trends for the key measures of employee satisfaction, involvement and development? For FY 03, the Staff Development and Training section of ETR offered 399 hours of classroom instructions with 5,107 attendees. This is a definite decline from FY02 in classroom instruction and represents the loss of a trainer who to date has not been replaced.

The decline in classroom attendance also clearly demonstrates the switch to the on line training. There were 21 hours offered on line with 23,934 individuals taking the training. In total, 420 hours of training was conducted either through classroom instruction or on line with 29,041 participants (Figure 7.3-1).

33

Training Hours and Attendance

677 4204894842

6615

7045031

29,041

0

10000

20000

30000

# Training Hours # Attended

FY 00 FY 01 FY 02 FY 03

Figure 7.3-1 (Higher is Better)

Of the 420 hours of classroom instruction offered in FY 2002-2003, there were 40 hours that qualified for Continuing Medical Education (CME), 36 hours for Nursing Continuing Education (NCEU) and 48 hours for non-discipline specific Continuing Education (CEU).

Of those courses offered in FY 2002-2003, there were 126 hours directly related to meeting the needs of the strategic plan and 272 hours focused on development of front line staff. In addition, 22 hours of supervisory training were offered (Figure 7.3-2).

Focus of Staff TrainingProvided by ETR

0

100

200

300

Strategic PlanPriorities

Front LineStaff

SupervisoryTraining

Ho

urs

of

Tra

inin

g

2002

2003

Figure 7.3-2 (Higher is Better)

To provide services effectively and efficiently, the Department is fully aware that employees need an up-to-date, technologically sophisticated computer network that supports clinical care. The agency’s IT plan is a roadmap to integrate information technology into consumer care by improving technological support to management and clinical staff.

As shown in Figure 7.3-3, significant resources have been made available to staff in the form of PCs, printers, data base access, and training.

Trends in Technology

010002000300040005000

Users Data-BaseUsers

PCs Printers StaffTrained

1999

2001

2002

2003 Figure 7.3-3 (Higher is Better)

The budget cuts of FY 01 through FY 03 created severe challenges on both employees and management.

As described in Category 2.1, almost all of the staff reductions were absorbed in areas serving non-priority consumer groups, in central administration, and inpatient facilities. For the most part, reductions were accomplished through attrition, or staff were offered reassignment to positions vacated through attrition.

Figure 7.3-4 shows the impact of the cuts on the three major organizational components of the agency’s workforce. Reductions were taken in administration and inpatient settings, in keeping with strategic plan priorities. CMHC was held harmless from staff reductions, in keeping with priorities.

Budget ReductionsImpact of Budget Cuts on Staffing

02040

6080

100

Inpt Comm Admin

Mill

ions

Jan '01Jan '03Jun '03

Figure 7.3-4

Employees show satisfaction with support services provided by the Department. Employee surveys for Human Resource

34

(Figures 7.3-5) and Network Services (Figure 7.3-6) both indicate satisfaction with component performance.

Human Resource ServicesCustomer Satisfaction Survey

3

3.5

4

4.5

5

Quality Responsiveness Courtesy

2001 2002 2003

Figure 7.3-5 (Higher is Better)

Additional elements related to internal customer satisfaction with DMH services is reflected in Table 6-2 which identifies key requirements of support processes.

Concern for employee safety and actions to improve the working environment are reflected in the reduced costs associated with work time lost due to injury (Figure 7.3-7). After years of increasing costs, DMH has reduced costs of payouts for lost time due to injury from $4 ½ M in 1998 to less than $1 M in FY 03.

Workers CompensationPayout for Lost Time Cases

$0$1,000,000$2,000,000$3,000,000$4,000,000$5,000,000

FY 98 FY 99 FY 00 FY 01 FY 02 FY 03

Figure 7.3-7 (Lower is Better)

7.4 What are your performance levels and trends for the key measures of supplier/contractor/ partner performance?

DMH monitors supplier performance through a continuous review process. All major contracts require that the vendor meet and maintain necessary licensure and accreditation requirements. Contract monitors are responsible for reviewing any changes in the status of the supplier.

The management contract with HMR to operate Campbell Veterans Nursing Home is monitored by staff of the Tucker Center to insure compliance with contract requirements. Campbell is fully licensed and certified by numerous agencies including State Health & Environmental Control and the Veterans Administration.

Just Care, Inc. is fully licensed by DHEC and is currently obtaining JCAHO accreditation for the operation of inpatient forensic beds.

Community mental health centers contract for local inpatient beds with private hospitals and individual vendors for residential services. The Center is responsible for insuring the vendor’s compliance with all licensing requirements.

DMH has continued to negotiate reduced fees under the management contract for food services. Under the contract for FY 03, DMH did not pay any management fee or administrative fee. Net food revenue (for outside sales) however, was shared by DMH

Network Services Customer Satisfaction Survey

Percent of Responses: Satisfied to Very Satisfied 80%

Timeliness and Effectiveness of Local Administrator in Solving Problems

87% Staff Helpfulness in Resolving Issue

93% Printer Availability 76%

Resolution Promptness and Effectiveness in Resolving Issues

81%

Overall Responsiveness and Effectiveness of Service

Figure 7.3-6

35

and Morrison’s on a 60%-40% split. Nutritional Services

Contract Management Costs

$0

$100,000

$200,000

$300,000

$400,000

FY 01 FY 02 FY 03Fees Food Sales

Figure 7.4-2 (Higher is Better)

7.5 What are your performance levels and trends for the key measures of regulatory/legal compliance and citizenship? DMH is subject to review/audit/survey by a wide variety of regulatory/legal bodies. Figure 7.5-1 provides an overview of many of these bodies, their function, and the status of our most recent review.

7.6 What are your current levels and trends of financial performance?

DMH has struggled to fulfill its commitment to improve services to its priority consumers and maintain its fiscal responsibilities in the face of

a $45 million reduction in state appropriations in the past three years, plus a loss of another $8.6 million in one-time

Figure 7.5-1 Legal Regulatory Compliance AGENCY OR

ENTITY FUNCTION Current Status

CARF National Accreditation All CMHCs accredited JCAHCO National Accreditation All inpatient facilities accredited VA National Accreditation of Veterans’ Nursing

Homes In compliance

HHS Program Integrity Audit

Medicaid Division of Corporate Compliance In compliance

HHS Program Staff Field Review

Review of programs and documentation to identify training and compliance issues.

In compliance

DMH Quality Assurance Team

Review of client care practices and medical records documentation for quality of care, accreditation and corporate compliance issues.

In compliance or action plan to achieve compliance

DMH Internal Audit

Review of administrative practices, policies and procedures for compliance with DoFS, Human Resources, and other regulations.

In compliance or action plan to achieve compliance

DMH Corporate Compliance

Regular review by DMH for conformance with DMH Corporate Compliance Plan

In compliance

DHEC Inspection of CRCF’s operated by Centers for conformance with regulations.

In compliance

DHEC Inspection of day programs preparing food for conformance with sanitation regulations.

In compliance

DHEC Inspections of inpatient facilities for compliance with regulations.

In compliance

Fire Marshal Inspection of facilities for fire safety In compliance Medicare Professional Review Organization

Review of medical records to determine appropriateness of Medicare reimbursement—contract organization of SC Blue Cross Blue Shield

In compliance

ADA Regulation of access for disabled In compliance

36

reductions. With state appropriations being 49% of our total budget (Figure 7.6-1), the challenge has been enormous.

FY 03 BudgetBy Revenue Source (in Millions)

0 50 100 150 200

StateMedicaid

Dispro MedOther FeesBlock GrantPt Fee Acc't

Veteran's AdmOther

Figure 7.6-1

The Department has made significant gains to offset these loses through an aggressive grant-seeking campaign, generating additional revenue from non-state sources, and reducing the use of expensive inpatient bed utilization by expanding community crisis programs.

In FY 03, DMH was awarded over $10 million in federal grants (Figure 7.6-2) to expand best practice programs, a major accomplishment in a time of federal, as well as state, diminishing resources.

Value of Grants Received

$0

$2

$4

$6

$8

$10

$12

1998 1999 2000 2001 2002 2003

Mil

lio

ns

Figure 7.6-2 (Higher is Better)

In an effort to generate non-state revenue, the Department has successfully increased Medicaid reimbursable services to priority populations. Through contracts with Health and Human Services, DMH bills for services rendered to Medicaid eligible mental health consumers served in community programs.

For example, approximately 55% of the patients admitted to community crisis units are

Medicaid-eligible. While inpatient psychiatric care cannot be billed to Medicaid, community crisis stabilization units can.

The average cost of an admission to a psychiatric hospital is $3,052, versus $975 for the cost of admission to a local crisis stabilization unit. Expanding community programs and reducing inpatient utilization not only conforms to stakeholder expectations, but it is also more cost effective.

DMH has also directed its services toward its priority populations: severely mentally ill adults and emotionally disturbed children. Figure 7.6-3 shows that DMH has actually increased billable hours of service to these primary consumer populations, in essence, providing more services to key customer groups with less money.

Billable Hours of ServiceConsumers with Major Mental Illness 2,6952,6572,5052,4362,353

132 165 186 198 229

0

1,000

2,000

3,000

FY 99 FY 00 FY 01 FY 02 FY 03

Th

ou

san

ds

Adults Kids

Figure 7.6-3 (Higher is Better)

The result of the department’s effort to increase non-state funding to compensate for reductions in state funding has been, essentially, an offset; the total dollars available to the Department from all sources – state, federal, grants, Medicaid, and patient fees – has remained essentially level, while costs have risen.

Figure 7.6-4 shows the net revenue from state and Medicaid for the past seven years.

37

State vs. Medicaid Revenue

0

50

100

150

200

FY 97 FY 98 FY 99 FY 00 FY 01 FY 02 FY 03Est.

Mill

ion

s

State Medicaid Figure 7.6-4 (Higher is Better)

DMH has done well to hold down the rising cost of expensive inpatient care. It has sought to promote local inpatient capacity, which is a preference of stakeholders. Figure 7.6-5 shows the per day cost of DMH acute care facilities compared to the average cost DMH pays through contract to private psychiatric facilities.

Inpatient Psychiatric Per Day Costs

$250

$300

$350

$400

$450

$500

1999 2000 2001 2002

Non-DMH Average DMH Average

Figure 7.6-5 (Lower is Better)

The TLC program, begun in 1991, is designed to return long term psychiatric inpatient consumers to live in the community through intensive support from CMHCs. To date, over 1,100 long term inpatient residents have participated.

The 363 consumers in the TLC program during FY 02 spent an average of 315 days in the hospital during the year before entering TLC, a total of 114,548 bed days. In FY 02, these same 363 consumers required only two DMH hospitalizations for a total of 43 days.

Not only is community-based treatment the right thing to do, it is financially a much more efficient use of fiscal resources (Figure 7.6-6).

TLC: Cost of Care- 363 Consumers

$39,796,675

$5,733,088

$0

$10

$20

$30

$40

$50

Pre-TLC In TLC

Mill

ions

Figure 7.6-6 (Lower is Better)

Figure 7.6-7 illustrates these figures on an average, per person basis. The Department is able to spend an average of $93,833 less on each consumer by providing intensive community based services than it spent providing institutional care.

Cost of Care, Per Person

$109,633

$15,794

$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

Pre-TLC In TLC

Figure 7.6-7 (Lower is Better)

It is for all of these reasons that the Department aggressively promotes crisis programs in the community to prevent unnecessary hospitalizations and promotes community preparation programs in the inpatient facilities to assist consumers in learning the life skills they need to succeed in their community transition.

The commitment to community-based services has allowed DMH to reduce hospital beds, close wards, and move funding into the community to generate new programs.

Community expansion has not been achieved at the expense of inpatient programs, however, but through new dollars and Medicaid revenue (Figure 7.6-8).

38

Community vs. InpatientPsych Expenditures

$0

$50

$100

$150

$200

FY 98 FY 99 FY 00 FY 01 FY 02 FY 03

Milli

ons

Psy Rehab Acute Community

Figure 7.6-8 (Higher is Better for Community; Lower is Better for Inpatient Psychiatric Rehab and Acute Inpatient)

Community expenditures have risen; long term psychiatric rehabilitation expenditures have decreased; and short-term/acute care has held essentially constant.

In keeping with its mission, the priorities of its stakeholders, and its responsibility as a good steward of the public dollars, SCDMH is Making Recovery Real for the mentally ill citizens of South Carolina.

Glossary of Terms and Abbreviations

ACT/PACT/RBHS – a set of case management programs delivered out of the CMHC offices, in the natural living environment of the consumer, urban or rural.

All-Hands Meeting – Quarterly meeting with State Director, open to all employees, to discuss the state of the Department.

Assembly – State Director’s monthly meeting of CMHC/facility directors, advocacy representatives and senior leadership. Quarterly, the Assembly includes CMHC Board representatives.

BASIS 32 – a 32 item assessment, made by the adult mental health consumer, of their symptoms and level of functioning.

BPH – Bryan Psychiatric Hospital, an acute care inpatient facility in the Columbia area.

CAFAS – Child and Adolescent Functional Assessment Scale, used by the clinician to evaluate the level of functioning and degree of symptoms in children and adolescents.

CARF – Commission on Accreditation of Rehabilitation facilities, one on the bodies which accredit DMH facilities.

CCET – Consumer-to-Consumer Evaluation Team, a consumer satisfaction measurement system run by fellow consumers.

CIS – Client Information System, data-base containing consumer information.

CLM – Computer Learning Modules, a computerized system for presenting and evaluating knowledge of standardized educational materials.

CME – Continuing Medical Education, physician continuing education credits.

CMHC – Community Mental Health Center. Commission – a seven-member body designated by

the state to oversee the Department of Mental Health.

Community Development Plan – the DMH strategic plan, also called “Making Recovery Real.”

Consumer – Person with mental illness served by the DMH.

Continuity of Care – a set of standards governing the provision of treatment to ensure seamless care is provided through hospital and community based care.

Corporate Compliance – process by which third party payers are assured that reimbursed clinical services are delivered as described.

CPM – Certified Public Manager, a managerial training program offered through state government.

DMH – South Carolina Department of Mental Health.

Dual Diagnosed – consumer diagnosed with more than one major psychiatric disorder: mental illness and alcohol/drug addiction.

EPMS – Employee Performance management System, the state’s annual employee appraisal system.

ETR – Education, Training and Research, a Division of the agency.

39

ETV – the state’s Educational Television Network, used by the Department to broadcast closed-circuit educational and interactive programming.

Governing Council – the 11 member senior leadership of the agency. Members are the State Director, Chief of Staff, Chief of Security, Medical Director, General Counsel, and the Directors of Behavioral Healthcare, Healthcare Reform, Communications, Administrative Services, the Center for Innovation, and Education, Training and Research (ETR).

HPH – Harris Psychiatric Hospital, an acute care inpatient facility in the Anderson area.

IQ – Intelligent Querry, a software package used by the agency to extract computer data into reports.

IT – Information Technology, the mainframe, area networks, and data systems of the agency.

JCAHCO – Joint Commission on Accreditation of Healthcare Organizations.

MST – Multi-Systemic Therapy, an in-home, intensive service to children and their families.

MHSIP – Mental Health Statistical Improvement Project, a multi-state project to design consumer satisfaction surveys for mental health consumers.

ORYX – JCAHCO required set of data required to be submitted monthly on the performance of inpatient facilities.

Pathlore – a computerized employee training registration and documentation system.

PIC – Performance Improvement Committee. QCRB – Quality of Care Review Board, a convened

group of experts charged with analyzing the events leading up to and through an outcome deemed adverse and making recommendations to the Department to prevent the event from recurring at the original site and throughout the agency.

QA – Quality Assurance, the process by which clinical services or documentation is monitored for adherence to standards, e.g., Medicaid, CARF, JCAHCO.

Recovery – A philosophy of mental health systems, supporting consumers’ ability to overcome the debilitating, stigmatizing effects of their disorder and assisting their empowerment.

Risk Management – the process by which potential clinical adverse outcomes are minimized in frequency or severity, or actual adverse outcomes are appropriately responded to as opportunities to improve services (root cause analysis, QCRBs, etc.).

SAP – computerized financial management system. School-Based – Services delivered by mental health

professionals within the walls of the school system.

State Plan – document required annually by federal government that specifies specific goals for expenditure of Block Grant monies.

State Planning Council – Stakeholder group who plans expenditures of federal Block Grant funds. The council is required to have at least 50% of its membership be non-DMH stakeholders.

Trauma – treatment and assessment, directed toward children and adults, to reduce the traumatic effects of psychiatric hospitalizations and previous life traumas.

TLC – Toward Local Care, a program to return long term psychiatric inpatient consumers to life in the community with intensive support from CMHCs.

Transition Council – Stakeholder group who plan and oversee the TLC program.

Utilization Review, the process by which clinical services or documentation are monitored to assure delivery of clinically appropriate treatment (a.k.a., clinical pertinence).

WSHPI – William S. Hall Psychiatric Institute, a specialty inpatient facility in the Columbia area, serving children and forensic populations.

Wrap – Intensive services, primarily for children, that “wrap” the individual in a full range of services to meet the psychiatric, emotional, social, and academic need.

1